BDS10023 - Maxillofacial trauma 3 (2020) (1).pdf

BDS10023 Maxillofacial Trauma 3 Aims The aim of this lecture is to detail the clinical, diagnostic and management aspects of mandibular traumatic injury Objectives On completion of this lecture, the student should be able to: Understand the clinical manifestations of mandibular traumatic injuries...

BDS10023 Maxillofacial Trauma 3 Aims The aim of this lecture is to detail the clinical, diagnostic and management aspects of mandibular traumatic injury Objectives On completion of this lecture, the student should be able to: Understand the clinical manifestations of mandibular traumatic injuries Understand the diagnostic processes for mandibular injuries Understand the principles of management of mandibular traumatic injuries Mandibular Fractures • Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity • Iatrogenic • Pathologic • Atrophic Mandibular Fractures • Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity • Iatrogenic • Pathologic • Atrophic Mandibular Fractures • Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity • Iatrogenic • Pathologic (Impacted teeth) • Atrophic Mandibular Fractures • Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity • Iatrogenic • Pathologic (Osteomyelitis) • Atrophic Mandibular Fractures • Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity • Iatrogenic • Pathologic (Neoplastic activity) • Atrophic Mandibular Fractures • Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity • Iatrogenic • Pathologic • Atrophic Mandibular Fractures • Location • Symphyseal fracture • Parasymphyseal fracture • Body fracture • Angle fracture • Ramus fracture • Coronoid fracture • Condylar fracture • Dentolaveolar fracture Classification of maxillofacial fractures • Relation to overlying tissue • Simple (open) • Compound (closed) • Complicated (soft tissue loss) Classification of maxillofacial fractures • Fracture line • Greenstick • Single • Multiple • Comminuted • Defect • Direction of force • Direct • Indirect Favorable or unfavorable? • Direction of fracture line • Oblique • Transverse • Sagittal • Direction of muscle pull • Favorable • Unfavorable Diagnosis of Mandibular Fractures Clinical Examination Diagnosis Imaging Inspection Palpation Clinical Examination • Pain and tenderness • Limited range of motion • Fractures dentition • Soft tissue laceration Clinical Examination • Extra oral Inspection • Swelling Clinical Examination • Extraoral inspection • Swelling • Hematomas Clinical Examination • Extraoral inspection • Swelling • Hematomas • Lacerations • Numbness Clinical Examination • Extraoral inspection • Facial asymmetry • Deviation of mandible on opening • Malocclusion Clinical Examination • Intraoral inspection • Hematomas • Laceration Clinical Examination • Intraoral inspection • Fractured dentition Clinical Examination • Intraoral inspection • Malocclusion • Anterior open bite with posterior premature contact Clinical Examination • Intraoral inspection • Malocclusion • Unilateral open bite with premature contact Clinical Examination • Palpation • Tenderness • Step formation • Mobility • Across fracture line • Condylar translation Clinical Examination • Palpation • Tenderness • Step formation • Mobility • Across fracture line • Condylar translation Clinical Examination • Palpation • Tenderness • Mobility • Across fracture line • Condylar translation • Step formation Panoramic radiograph (92%) Reverse Towne’s view Computed tomography • Multiple trauma (can’t assume position for plain radiography) • Severe displacement • Limited range of motion due to bony obstruction Imaging Imaging • Panoramic radiograph Imaging • Panoramic radiograph • Reverse Towne’s view Imaging • Panoramic radiograph • Reverse Towne’s view • Computed tomography Principles of management of mandibular fracture Treatment objectives 1. Obtain stable occlusion 2. Establish a full range of interincisal opening and mandibular excursive movements 3. Minimize deviation of the mandible 4. Produce a pain-free articular apparatus at rest and during function 5. Avoid internal derangement of the temporomandibular joint on the injured or the contralateral side 6. Avoid the long-term complication of growth disturbance. Treatment Options Closed reduction Open reduction with internal fixation Closed reduction Length of fixation • Adult 3-4 weeks • Children 2-3 weeks • Older patients 6-8 weeks Length of fixation of condylar fractures IMF • Arch Bar • Erich’s arch bar IMF • Arch Bar • Erich’s arch bar IMF • Arch Bar • Erich’s arch bar • Schuchardt arch bars Techniques of fixation • Direct wiring Techniques of fixation • Direct wiring • Ivy loops Techniques of fixation • Direct wiring • Ivy loops • IMF screws Techniques of fixation • Direct wiring • Ivy loops • IMF screws Techniques of fixation • Direct wiring • Ivy loops • IMF screws Techniques of fixation • External pin fixation Techniques of fixation • External pin fixation Techniques of fixation • External pin fixation Indications Open reduction of condylar fracture • Absolute indications • Relative indications Mode of fixation • Intraosteal wiring • Rigid fixation • Functionally stable fixation Open reduction Unfavorable or Unstable Fracture Prolonged Delay in Treatment of the Fracture Complex Facial Fractures Medically Compromised Patients Concurrent Condylar Fracture Associated with Fractures elsewhere in the Mandible Indications for Open reduction Intraosseous wiring • Simple wiring • Figure of eight • Circummandibular wiring Rigid fixation Plates and screws Delayed Union and Nonunion Infection Malunion Complications Nerve injury Growth alteration Temporomandibular dysfunction (TMD) Internal derangement Ankylosis Complications Delayed Union and Nonunion • No Treatment • Inadequate or improper fixation • Inadequate fixation time Complications Infection • Interfragmentary movement • Foreign body • Previously existing infection Complications Malunion and malocclusion Complications Nerve injury Complications Growth alteration and ankylosis Complications Growth alteration and ankylosis • Reading material: 1. Wray D et al; Textbook of General and Oral Surgery, Churchill Livingstone 2003 pp 89-102 2. Kerawala C, Newlands C. Oral and Maxillofacial Surgery. Oxford University Press, 2010 pp 34-41 3. Brennan et al. Maxillofacial Surgery Volume 1. Elsevier 2017 pp 50-92 TO SUM IT UP : • Diagnosis of mandibular fracture requires systematic clinical and radiographic examination • The objectives of treatment should be clearly outlined and the treatment planning should put in mind the simplest and most conservative approach to achieve them Aims The aim of this lecture is to detail the clinical, diagnostic and management aspects of mandibular traumatic injury Objectives On completion of this lecture, the student should be able to: Understand the clinical manifestations of mandibular traumatic injuries Understand the diagnostic processes for mandibular injuries Understand the principles of management of mandibular traumatic injuries Thank you